Risk of refracture increased with greater follow-up in patients treated with short or long IM nails

After 5 years, researchers found no differences in costs between short and long IM nails.

Issue: September 2016

Longer follow-up after treatment of pertrochanteric hip fractures with either short intramedullary nails or long intramedullary nails lead to a steady increase in incidence of ipsilateral femur refractures, according to results.

“In patients surviving at least 5 years after a hip fracture, there is about a 10% incidence of refracturing that same femur somewhere down the shaft,” Eric Lindvall, DO, chief of the Department of Orthopedic Surgery at the University of California, San Francisco Fresno, told Orthopedics Today. “If you feel your patient is going to survive at least 5 years, then he or she could potentially be that one in 10. Locking the nail distally seems to be protective against refracturing.”

Short vs long intramedullary nail

Lindvall and his colleagues treated 609 patients with 610 pertrochanteric hip fractures with either a small intramedullary (IM) nail or a long IM nail from 2005 to 2011. For both groups, ipsilateral femur refracture rates were recorded and a cost analysis was performed to compare short and long IM nails while accounting for observed refracture rates and surgical/hospital costs to determine the overall cost of each implant.

Results showed while there was a steady increase in ipsilateral femur refracture rates from year 1 to year 5 in both groups, union rates were equivalent between cohorts and averaged more than 97%. Although patients treated with a small IM nail experienced a higher refracture rate at each time interval vs. patients treated with a long IM nail, the differences were not of statistical significance. Researchers found 47% of nails were locked distally and 15 of the 16 refractures occurred in nails that were not locked distally, a factor that was determined by univariate logistic regression to be a significant refracture risk factor.

Researchers noted long IM nails were an average of $439 more expensive than short IM nails. However, overall costs showed treatment with short IM nails had a greater cost of $1,014 compared to long IM nails during a 5-year follow-up period.

Controlling for cost

Lindvall noted a prospective randomized study should be carried out to help control for cost. A similar study looking at costs in the Veterans Affairs (VA) system showed higher costs with long IM nails than short IM nails with 1-year follow-up, he said.

“Some of the implant prices we found across the country are three-times higher in the VA system than what many community hospitals are charging just because the market forces are not present,” Lindvall said. “We are trying to look at that in more detail to find out the cost differences amongst government facilities vs. the private sector ... which is valuable information with today’s ever-increasing cost-containment strategies.”

However, he added follow-up beyond 5 years may be difficult since the patient population dwindled significantly by 5 years.

“The problem is following these patients long-term because they have such a high mortality at 2 years and 5 years,” Lindvall said “Longer follow-up than 5 years is almost not a viable study because so many patients [are deceased].” – by Casey Tingle

Reference:
Lindvall E, et al. J Orthop Trauma. 2016;doi:10.1097/BOT.0000000000000420.

For more information:
Eric Lindvall, DO, can be reached at the department of orthopaedic surgery, University of California, San Francisco Fresno, 2823 Fresno St., Fresno, CA 93721; email: elindvall@fresno.ucsf.edu.

Disclosure: Lindvall reports no relevant financial disclosures.